Healthcare Provider Details

I. General information

NPI: 1275958308
Provider Name (Legal Business Name): YONG SHI, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 CORLIES AVE SUITE 7
NEPTUNE NJ
07753-4860
US

IV. Provider business mailing address

1820 CORLIES AVE SUITE 7
NEPTUNE NJ
07753-4860
US

V. Phone/Fax

Practice location:
  • Phone: 732-775-6664
  • Fax: 732-775-6680
Mailing address:
  • Phone: 732-775-6664
  • Fax: 732-775-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06999900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA06999900
License Number StateNJ

VIII. Authorized Official

Name: DR. YONG SHI
Title or Position: PHYSICIAN
Credential: MD
Phone: 732-775-6664